<div class="layuimini-container">
    <form id="app-form" class="layui-form layuimini-form">
        
        <div class="layui-form-item">
            <label class="layui-form-label">会员ID</label>
            <div class="layui-input-block">
                <input type="text" name="user_id" class="layui-input" lay-verify="required" placeholder="请输入会员ID" value="0">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">提现流水号</label>
            <div class="layui-input-block">
                <input type="text" name="order_sn" class="layui-input" lay-verify="required" placeholder="请输入提现流水号" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">真实姓名</label>
            <div class="layui-input-block">
                <input type="text" name="true_name" class="layui-input" lay-verify="required" placeholder="请输入真实姓名" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">审核状态</label>
            <div class="layui-input-block">
                {foreach $select_list_check_status as $k=>$v}
                <input type="radio" name="check_status" value="{$k}" title="{$v}" {in name="k" value="0"}checked=""{/in}>
                {/foreach}
            </div>
        </div>

        <div class="layui-form-item">
            <label class="layui-form-label">转账状态</label>
            <div class="layui-input-block">
                {foreach $select_list_cash_status as $k=>$v}
                <input type="radio" name="cash_status" value="{$k}" title="{$v}" {in name="k" value="3"}checked=""{/in}>
                {/foreach}
            </div>
        </div>

        <div class="layui-form-item">
            <label class="layui-form-label">审核失败原因</label>
            <div class="layui-input-block">
                <input type="text" name="check_reason" class="layui-input" lay-verify="required" placeholder="请输入审核失败原因" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">付款异常原因</label>
            <div class="layui-input-block">
                <input type="text" name="cash_reason" class="layui-input" lay-verify="required" placeholder="请输入付款异常原因" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">审核时间</label>
            <div class="layui-input-block">
                <input type="text" name="check_time" class="layui-input" lay-verify="required" placeholder="请输入审核时间" value="0">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">转账时间</label>
            <div class="layui-input-block">
                <input type="text" name="cash_time" class="layui-input" lay-verify="required" placeholder="请输入转账时间" value="0">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">账户类型</label>
            <div class="layui-input-block">
                {foreach $select_list_account_type as $k=>$v}
                <input type="radio" name="account_type" value="{$k}" title="{$v}" {in name="k" value="1"}checked=""{/in}>
                {/foreach}
            </div>
        </div>

        <div class="layui-form-item">
            <label class="layui-form-label">提现账户</label>
            <div class="layui-input-block">
                <input type="text" name="account" class="layui-input" lay-verify="required" placeholder="请输入提现账户" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">收款二维码</label>
            <div class="layui-input-block">
                <input type="text" name="qrcode" class="layui-input" lay-verify="required" placeholder="请输入收款二维码" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">开户行</label>
            <div class="layui-input-block">
                <input type="text" name="bank_name" class="layui-input" lay-verify="required" placeholder="请输入开户行" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">银行卡类型</label>
            <div class="layui-input-block">
                <input type="text" name="bank_type" class="layui-input" lay-verify="required" placeholder="请输入银行卡类型" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">提现金额</label>
            <div class="layui-input-block">
                <input type="text" name="cash_fee" class="layui-input" lay-verify="required" placeholder="请输入提现金额" value="1.00">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">手续费</label>
            <div class="layui-input-block">
                <input type="text" name="handling_fee" class="layui-input" lay-verify="required" placeholder="请输入手续费" value="0.00">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">到账金额</label>
            <div class="layui-input-block">
                <input type="text" name="pay_fee" class="layui-input" lay-verify="required" placeholder="请输入到账金额" value="">
            </div>
        </div>
        <div class="layui-form-item">
            <label class="layui-form-label">第三方订单号</label>
            <div class="layui-input-block">
                <input type="text" name="transaction_id" class="layui-input" lay-verify="required" placeholder="请输入第三方订单号" value="">
            </div>
        </div>
        <div class="hr-line"></div>
        <div class="layui-form-item text-center">
            <button type="submit" class="layui-btn layui-btn-normal layui-btn-sm" lay-submit>确认</button>
            <button type="reset" class="layui-btn layui-btn-primary layui-btn-sm">重置</button>
        </div>

    </form>
</div>